Building relationships

I love it when I bond well with a patient when I'm on L&D.  I've had several lately that really stand out in my mind, and let me just say -- not all of them felt super warm and fuzzy when I first met them!  I realize it takes a bit of time for some people to warm up to a caregiver - they have to build a relationship, learn to trust their caregiver(s), create some kind of bond.  Other people, we just hit it off right from when we say "hello".

I care for many women from a wide variety of cultures, and some of the cultural norms are very "hands off", and may seem like there is an emotional as well as physical distance in the nurse-client relationship.  But then the new mom will surprise me, and give me this huge hug, and want to get a picture taken with me and her new little baby, and she just grips my hand and doesn't want to let go.  It just blows my perceptions of those "cultural norms" out of the water!

Building relationships with clients is one of my favorite aspects of both being a nurse, and being a midwife.

First year as a CNM -- job searching

So, I graduated from my MSN program, passed my certification exam, am working on applying for my CNM state license, and I am also looking for a CNM position.

I have an interview this week for a low income women's health clinic, where there is currently only one CNM (and several MDs).  The CNM is a friend of mine, and is so overwhelmed with how busy she is in the clinic!  She definitely sees the need for at least one more CNM to share the workload in the clinic and call time in the hospital.  Currently, she sees at least 5-6 new OB clients each day she is in the clinic.  EACH DAY!!  Her schedule is so packed that new OBs can't make a first appointment for several months.  Definitely a need for more providers!

Another job lead seems to be in a holding pattern.  This is a laborist midwife position for another low income women's clinic, and would be hospital only.  There are currently no CNMs working with this clinic, so this is a new position.  I have heard from the assistant director of nursing, and she said that the HR dept should be calling me in about a month to schedule an interview.

None of the private practices nearby are hiring CNMs.

I haven't yet branched out to other areas within an hour's drive, but I may need to start doing that.  In the meanwhile, this CNM is continuing to work diligently as an L&D RN.  Oh, and taking advantage of the fact that I have downtime.  I've read a huge pile of fiction as well as non-fiction books in the past few weeks.  It feels SO GOOD to have downtime again!

Things that I wish my school had better prepared me for: searching for a job, contract negotiations, interviewing for jobs, malpractice insurance and liability.  Things that I'm sure I will also need to know in the (near) future: billing and coding.  We did review this a little bit at Frontier, but I suppose that it's one of those things where you have to actually do it (frequently, repeatedly) to learn it.  It also changes from year to year.  Health information technology (IT) would have been a good subject to implement into the courses as well.

I don't blame Frontier for not covering each and every topic related to midwifery.  After all, I think they did an amazing job with providing the basic midwifery education that's required as a beginning practitioner.  I feel that my education has given me a solid base upon which to build up my midwifery practice.

When I finally secure a position, that is.

Til then, just sign me --- well educated RN.

The past few weeks

So, I'm still waiting for the approval from the AMCB to schedule my certification exam to become an official CNM.  Yes folks, I took that comp exam and passed it way back on 4/10, electronically submitted my application to AMCB, paid my $500 fee, and am still waiting to schedule.  Sigh.  Good things come to those who wait ......... patiently.

In the meanwhile, I've been working on L&D, as usual.  There are some days when I think to myself, maybe I'll just stay working as an RN, but with a fancy degree?  Then things happen, and I think to myself, geeze, why couldn't I have that little title of CNM after my name and be working as one RIGHT NOW?!??

Yeah...so I'm a bit contradictory and conflicts rage in my brain.  But darnit, I am ready to move on over into my CNM role!  I'm scared at the thought of much higher responsibility and liability, but super excited about the fact that I will be able to have a greater function/role in helping women during pregnancy, birth and beyond.

I have noticed that the docs at work are much more trusting in my thoughts and opinions on how to manage labors.  One doc in particular is taking a more proactive, woman-centered approach in actually asking the woman what SHE wants to do.  Score!  He also outright asks me --- how would you manage _____ ?  Then he and I actually have a discussion on management options, possible outcomes.  Holy crap --- I'm feeling much more like a colleague!

I recently had a family member thank me for being so thorough and complete in my care for a more complicated pregnant patient.  It really felt great to have a family member take the time to say "thank you" like she did.  I was only doing what I felt was best in caring for this person -- even if it meant triple and quadruple checking with the patient with how she managed her illness at home, so that she would receive the utmost excellent care in the hospital setting.

Well, back to prepping for my certification exam!!

Role transition

The more that I am in my clinical site, the more I am enjoying my role transition to midwife.  I'm finding that I am liking my role as the nurse while at work, less and less.  This only proves to me that I am -- without a doubt! -- in the right environment for midwifery at my clinical site!  It also proves that yes, all of this struggle and huge student debts are worth it on my path towards midwifery.  From the basic classes (theory, research, pathophysiology, etc) to the middle level courses (ante, intra, post/NB) to the advanced level courses.........and finally in my clinical site, where I am putting it all together!

I am incredibly grateful to be at my clinical site.  These are fabulous co-workers and I can totally envision myself finding a permanent role at this site.  God/goddess willing, of course!

My clinical site ~ women are treated as true partners in their care.  Women are given choices, ALL of the choices, and are encouraged to ask questions, discuss their options with family/support persons, and then make their own choice as to what they would like their plan of care to be.  Food and drink are highly encouraged in labor (yes, even with VBAC women!), ambulation and intermittent monitoring is the norm, and nursing care is superb.  The hospital itself is a laid back, relaxed environment, where women and their families are treated well and with respect.  No rigid rules and regulations for family, visitors, and times for visitation.

It's quite a shell shock to go from such a warm, loving, woman & family centered environment........to the rigid and often times noisy environment where I work.

Things you won't hear your L and D nurse say (but she's thinking them)

What I'm thinking versus what I really say

I have never seen something like that before!
Well, that's interesting.

What IS that?!?
I'm not quite sure. Let me get your doctor or midwife.

All 20 of your visitors are your labor support? Sure.
That's wonderful that you have so many supportive people to help you through labor.

Grandma is drunk. I can smell it from 10 feet away.
Grandma, you look a little tired. Can I show you to our waiting room so you can rest your feet for a bit.

Oh crap! A cord prolapse!
Apparently, the cord is coming out first. This is urgent, and we need to go for a c-section right now. A lot of people are going to be coming in to get you ready, so don't panic. I'll be right here with you.

Oh crap! SHOULDER DYSTOCIA!
We need to get your legs far back and you need to push really hard now, alright?

Oh crap! This is a LOT of bleeding! Why won't it stop???
It appears that you're having some extra bleeding.

Where is the doc when I really need him/her??
The doctor is on his way.

Of course your doctor will be with you all throughout your labor - NOT.
Your nurse is with you for the majority of your labor. The doctor comes in when you're close to the birth.

I have no clue what I'm feeling (during a cervical check).
I can't quite reach your cervix. Do you mind if I have another nurse check?

I hope I never see that again.
Well, that was interesting.

This is the first time I'm doing this.
I've done this lots of times.

What a funny looking kid!
Oh look, he has your eyes!

The call bell needs to be taken away from you. You're on it every 2 minutes!
Is there anything I can get for you?

Your pain is 10/10? Seriously? I don't believe you when you're on the phone and laughing with your "guests".
.....blink blink....... What have you done to help ease your pain?

History of rapid births. Better have everything set up 20 minutes ago!
Tell me when you feel like the baby is coming, I trust you 110%!

She has five kids already, working on #6. And she's not old enough to drink. Hip hip hurray for welfare!
What method of birth control do you plan on using after the baby is born? (Not a normal question when admitting a laboring woman. But very pertinent.) Oh, you haven't thought about that? Let's review your options.........

Aw crap! Another laboring patient. We are packed to the gills with no spare labor rooms. WTF are we doing to do??
Hi there! How can I help you?

Ahhhh, the wheelchair sign. She's either 10 cm or has a closed cervix. I'm betting on the closed cervix.
Hi there! How can I help you?

Ahhhh, the positive towel test. She's definitely ruptured her membranes!
Let's get you into a room right away.

Your doctor is an ass. I wouldn't let him touch me, even if I was dying.
All of his patients seem to really like him.

A multip who is breech, and in active labor at 6 cm, and is sectioned. WTF didn't he deliver her vaginally?!
You should be able to have a VBAC next time, if you choose.

Placental abruption, from the nurse's point of view

It was change of shift, and I was just starting out my shift on L&D. *Annie and her husband *Frank (*names changed*) had also just arrived on L&D. Annie had noticed some vaginal bleeding, and she and her husband were concerned about this, so they decided to come in to be evaluated.

Annie had a known history of a partial, but stable, placental abruption. I walk in the room to find two nurses valiantly trying to establish an IV site and maintain fetal heart tones.

**thump...thump...thump**

The fetal heart monitor is kicking out a too slow rate ~ about 80-90 beats per minute. Oxygen is on and one of the nurses turns Annie on to her side.

**thump.........thump..............thump**

Even slower.

I jump in and deftly insert an 18 g IV site, pulling various tubes of blood off of the line, then hook up IV fluids.

**thump..................thump............................thump**

Slower and slower.

We race Annie back to the OR. Her poor husband Frank, bless him, understood the implications of what was happening.

Everyone is rushing around in the OR, working to get Annie transferred to the OR table, catheter placed, instruments at the ready. Annie looks around, about ready to burst into tears. I'm on the phone with the NICU, telling them we have a STAT c/s for an abruption, hearts are down.

I walk over to Annie, get down close to her ear, gently touch her arm and hand, and whisper to her:

"My name is ____. I know it's very scary right now, but we're doing many different things at one time to help get your baby out. You're going to feel the catheter go into your bladder in just a second here - it's going to burn and hurt for a minute. Cold gel on your belly as we listen to your baby's heartbeat - listen to that! It's up again at 120 beats per minute. That's very good!"

Annie nods her head, tears welling in her eyes. "His name is Matthew."

"The baby?" I ask her.

"Yes, his name is Matthew."

"Annie, we're going to work very quickly now to get Matthew out, and we will take very good care of him and you. You're going to go to sleep in a just a few seconds here, but I will be with you and Matthew the whole time."

"Save my baby," she says, as we tightly grip each others hands.

Cold antiseptic solution is splashed on her belly as Annie is quickly put under general anesthesia.

**incision!**

**membranes ruptured - bloody fluid!**

**baby!**

An immediate lusty cry is heard as baby Matthew is born.

Audible sighs of relief can be heard throughout the room as Matthew is dried off and assessed by the NICU team.

Frank, now a proud new papa, is escorted into the OR to greet his new son.

**smiles**

A very positive outcome for a situation that could have been much more dire.

Times like these make me feel very honored to be present at the amazing miracle of birth.

Happy birthday Matthew!

AtYourCervix gets a break for Christmas

I can't believe that I managed to do this, but I am off both today and tomorrow.

SCORE!!!!!

I don't know if I've ever been off both Christmas Eve and Christmas Day in my years as a nurse.

So, even though I won't be there to lovingly help little ones into the world, my fantastic co-workers will.

A moment of silence for all of the nurses working today and tomorrow.

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By the way, payback for these two nice days off will be hell. I'm working a ton of shifts in a row for the New Year's weekend, and will subsequently miss my big extended family get together for the holidays. ::sigh::

Happy Holidays everyone!

From the patient's perspective

I had the pleasure (gack!) of being a patient recently. Well, I can actually tell you quite a few stories of being 'the patient' -vs- being 'the nurse' -vs- being 'the patient that's a nurse'.

Often times, I have been very tired, sore, aching, and ready to leave when it's the end of my shift as the nurse. I hope I don't come across as super eager to go home at that time to my patients.

Note: I'm not one to go to the ER. Seriously. But when I recently had a severe incidence of abdominal pain that didn't abate, and I had other alarming symptoms going on, I hated to do it........but I ended up needing EMS. Unfortunately, I was also physically unable to walk, much less get to my car to have someone drive me to the ER.

I had the unfortunate pleasure of being a patient during change of shift in the ER. My first nurse was obviously ready to go home. She had that haggard look of having come to the end of a very long day. I don't know if it was an 8, 12 or 16 hour shift for her. Her shoes made fairly loud clomping noises when she would come into my cubicle. (Then again, that could just be her shoes!) She was on her cell phone (work cell phone) when she started coming into my cubicle area, but was still talking on it. I heard a snippet of "are you relieving me?" before she glanced at me and turned back out of the room to finish her short chat on the phone. She came back in, wrapped up the end of her shift duties with me, then left the room. All interactions between her and I were very no-nonsense. No warm and fuzzy connections either.

Oh, did I mention, I did NOT say to anyone that I was a registered nurse. Except to the ER MD when he was discharging me. (He offered to keep me overnight for observation, but I said I was ok to go. The only reason why my being a nurse came into discussion was when he asked why I decided to come to his ER that evening, when I had all of my surgeries and hospitalizations at another hospital. I explained that I work for that hospital group as an RN, but this ER was closer to where I was that evening.)

Anyhow......back to my point of view as the patient. This first nurse - was either tired and ready to go home, or didn't like her job. That's just how she came across to me. I wonder if I come across that way to patients at times? I just know that it annoyed me that she seemed distanced from her role as the nurse.

The next nurse (night shift): she was better. Then again, she was at the start of her shift. She actually hung around in my cubicle to listen to me explain a little bit more of what was going on, and how I was doing. She was cool.

The x-ray transport dude: either hated his job (it sure seemed that way), or he was also at the end of a very long shift and ready to go home. I was not impressed.

The x-ray tech: nice girl. Professional. No -nonsense.

The ER doc: I was impressed. He did a quick assessment immediately upon my arrival via EMS. Even though he didn't know what was going on by my test results, he offered to keep me overnight. I declined. My symptoms by this point were much improved, and I was able to go home. He even gave me a copy of my lab/x-ray results for my surgeon to have a copy, since this hospital wasn't associated with the hospital I normally go to. (Thank you, kind ER doctor!)

Oh, and you want to talk about feeling like you wasted everyone's time? That would be me. The pain and symptoms I had were all pointing at a serious GI complication, but yielded no firm diagnosis and eventual abatement of symptoms. Although I was 1000x grateful for the pain to be tremendously decreased, I felt like I came across as someone who abuses the EMS system.

By the way: the pain? Still there. Very dull.

Poor morale, sucky management

I am just physically and mentally drained after working these last several weeks. I mean, seriously, it is busy - non-stop! We've had several nurses resign in the past few months. Have we filled those positions? Nope. Six nurses gone, with one new hire. NOT ENOUGH!

We are not only full to the brim with a wide variety of patients and acuities, but we are also chronically short staffed with nurses. Management has been working (literally, they're working on the unit as staff nurses!) to fill in the holes in the staffing, but it's still not enough.

When will they ever get it? We need more nurses! Not more changes to the silly rules. Not some weak gestures of bags of chips as a token of your "thanks" to how hard we're working.

The annual review by the unit manager of addressing our current needs was full of bullshit. Not once, in the entire list of areas that need improvement, was there a word at all about hiring more nurses.

Yes management - wake up! WE NEED MORE STAFF NURSES ON EACH SHIFT! Things are becoming unsafe for the pregnant women we are caring for. You bet your bottom that I am writing incidents up to Risk Management when things go wrong.

How about a correlation of the recent increase in staff who have back injuries, neck injuries, and knee injuries related to constant wear and tear on our bodies from floor nursing? Has that even been addressed?

I am just thoroughly disgusted by how poor the morale is on my unit. We are an awesome crew of nurses. Let's hope that management finally sees the light and fixes our ongoing problems with staffing before even more nurses leave or are injured on the job.

Nurses' Week, the L&D Version

Let's see........

I found out Miss AMA (against medical advice) came in the next day and delivered her baby. I'm so glad to not have to worry about being her nurse should she come in, because now that point is moot.

Nurses' Week - we're not officially celebrating it at work until next week. Go figure. I think we get cookies from management for being such hard working, fantastic, Magnet nurses. Can I have more vacation time instead please? Or a nice raise? Or ... how about we actually hire more nurses so we're not chronically short staffed?

Like I've said before, labor and delivery is either feast or famine. It's rarely anything in between, or so it seems. My last shift, we started out ok, but we were pretty much all doubled up with patients and I knew that if the crap hit the fan, we'd be done for.

Incoming! Incoming! Incoming!

It's like all of the pregnant women go into labor at one time. Like I said, we're all doubled up already, and no less than (at least!) 6 pregnant women come in, one right after the other.

One looked like she was about ready to deliver in the wheelchair. (Actually: only 1 cm dilated. Dodged a bullet with her.)

Another one looked like she was actively laboring. Her nurse checks her: 7cm and ruptured membranes. She precipitously delivers her baby a few minutes later. Absolutely NO doctors or midwives available - all are in deliveries. The patient's doctor was on her way in.

Rule out preterm labor - ruled out, sent home.

Rule out preeclampsia - not preeclamptic on initial assessment. Needs more evaluation to finish up her assessment.

Rule out labor - ruled out, sent home. She had probably the shorted outpatient visit of everyone, only because her doc was immediately available to assess, check, and send her home with discharge instructions.

Rule out labor - dunno what happened with her. I put her on the monitor and then my relief night nurse came and took over.

Status post seizure at home. Don't know what was going on with her, because she came in around change of shift.

I'm working on giving report on 1 of the 4 (or more?) I ended up taking care of when.......help needed in the PACU immediately. No one available but me, so I'm off and running. The poor lady back there was sick, sick, sick. She ended up going back to the OR. I stayed to help out, assisting the doc and the other nurses caring for her, trying to get her stabilized. I hope she does ok. It was looking pretty bad when I left.

Happy Nurses' Week indeed.

Creativity, projects, writing & school

You like the new layout? I played with it last evening. I wanted to create a header that showcases some of the flowers I've photographed lately. I was tired, so I didn't make a new background design/color, so I just chose one that I had made previously.

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I started the new school term on Monday. The first day is always a day of copying/pasting/printing the syllabi and individual modules for each course, as well as reviewing and reading the introductory material. I also try to create some sort of calender for the term, with due dates filled in. Yeah, I'm an organized person like that. I think you really need to be, to succeed in a program like this. I mean, the program is 100% student driven and initiated. If I don't do it, it doesn't get done. If I procrastinate, I will fail the class. Simple as that.

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I received some follow up info on an intervention I implemented at the OB/CNM office where I did my community health practicum, way back in October/November 2009. Apparently, they've really taken off with the implementation of my postpartum depression information and follow up. I also included information about local support groups for PPD. Patients have been going to them, thanks to my intervention from my class! WOW!! I wrote to the program director at my school for the Bridge curriculum, and she suggested writing it up for one of the Maternal/Child Health Nursing journals.

So, I took her advice, and started researching how to write and publish an article with one of the journals. I'm just at the beginning stages, so I don't expect to see any completion in this article in the next few weeks (or even months). Especially now that I'm at the beginning of a school term, with my own deadlines and such.

However, I am super psyched! I love to write (as you can tell), and love to express my creativity while educating women/families. This could very well be just the tip of the iceberg for my writing and scholarly future.

(And, it looks good on a resume/CV to say you've published articles in journals!)

Frustrations

In light of what has recently happened (that, which I cannot give details about, and I'm very sorry that I can't), I am glad that I am in a position to hopefully see some change come about.

After witnessing obstetrical atrocities in the hospital setting, I am more than ever sure about the path I am taking towards midwifery. Yes, there have been moments where I doubt my entire career as a nurse. There are times where I want to totally get out of labor and delivery. But, after reading about nursing in other clinical areas, and talking to other nurses, I realize: atrocities happen everywhere in medicine & nursing. You cannot escape them.

Better choice then is, since I am already in the hospital system (and the maternal health system), is work towards positive change. Let's face it, the whole maternal care system in the United States need an overhaul. Shall I go through the negatives alphabetically? Or should I just move on and look at what I can do to help change things?

One woman and child at a time. At this point in time, that is all I can do. I can educate and advocate for the women that come under my care. Women that come under my care do so for a very short period of time in their lives. At most, eight hours (or more, if I stay over my shift).

I look around me while at work, and see how every one of us is failing the maternity system. I am frustrated that I can't "fix" everything.

I know I am not the only nurse who feels this way. I KNOW IT!! We get report on all of the women in the unit at shift change. We all mumble the same comments when something that is total BULLSHIT is going on. Yet.........who is brave enough to stand up and say that it's wrong, and it needs changed? Who follows through with making changes?

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Two day inductions that end up as c-sections for "failed induction". Same group of physicians. Repeatedly.

Not fast enough progress in labor. C-section by 6pm.

Pitocin to distress. Stat c-section. (Oh, we are making glorious headway with this one!! We are taking better control, as nurses, in how we "manage" pitocin drips.)

Induction -->pitocin -->epidural -->fetal distress -->c-section.

Too many laboring women to few nurses --> no one-on-one labor coaching.

Denial of VBAC option, or never being offered the option. Even when presenting in active labor and advanced dilation.

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One person at a time. One woman at a time. One birth at a time. Things WILL get better.

Personal cell phones while working

Should nurses be allowed to have personal cell phones while working? Should personal cells phones be banned in the hospital for nurses (and other staff)?

I see a LOT of nurses, physicians, and other staff members at the hospital with their personal cell phones while on duty. Some are texting (ok, many are texting), some on Facebook, others....?? who knows what.

Our hospital's official stance is no personal cell phones allowed while in the workplace. Of course, if you are on your break, it's not a problem.

Do different rules apply for different employees? Technically, the physicians are not employees, and tend to use their cell phones for work related phone calls. Nurses are supplied with hospital cell phones for use for hospital only phone calls.

Here is just one thread on allnurses.com about texting while at work.

Thought? Comment?

Did my water break? Tests used to tell if you have ruptured membranes.

Sometimes, medicine and nursing is not an exact science.

Many times, we have women come in to evaluate if their membranes are ruptured. There are several observations/tests used to determine if the membranes are possibly ruptured.

Test #1 – visual inspection of the labia: if things are saturated, you can pretty much guarantee that it’s ruptured membranes.

Test #2 – nitrazine paper: this tells the pH of the fluid. Acidic fluid doesn’t change the color of the yellow test paper. Alkaline fluids change the paper to a blue color. The darker the shade of blue, the more alkaline the fluid is. Several things can cause the nitrazine to test positive (change color): amniotic fluid, semen, vaginal mucous and secretions (vaginal fluids can have a very high pH), feces, and blood. So, you can see it’s not an exact test.

Test #3 – speculum exam: this is where we visualize the cervix and look for “pooling” of fluid from the cervix. This is usually a good indicator that it’s amniotic fluid. The provider will usually have the woman cough to help express any fluid from the uterus into the vagina.

Test #4 – looking at a specimen of the fluid on a slide under the microscope. This is where we look for a pattern called “ferning”. When amniotic fluid is placed on a slide and allowed to air dry, it will take on a distinctive ferning pattern under the microscope. However, amniotic fluid doesn’t fern before 20ish weeks, which makes this test difficult to use for diagnosis.

Test #5 – injection of indigo carmine into the uterus via an amnioscentesis. Indigo carmine is a bright blue dye. When it’s injected into the uterus via an amnio, we watch for fluid leakage out of the vagina. If the woman leaks blue fluid, then it’s positive. This is a very definitive test, but also very invasive and has some risks associated with it.

Test #6 – ultrasound: the provider looks for pockets of fluid around the baby. If the fluid pockets and measurements are adequate, then either there was a lot of fluid (polyhydramnios) in the first place, or the membranes haven’t leaked a significant enough to affect the level of fluid left around the baby. Sometimes, a high leak that seals itself will show normal fluid levels on an ultrasound.